Download What you should know about "quick fix" for your orthodontic problem

IN BRIEF
• Provides a considered opinion from the
Faculty of Dental Surgery of the Royal
College of Surgeons of Edinburgh on the
limitations and potential consequences of
short-term orthodontics.
• Cosmetic practitioners, including
general dental practitioners undertaking
short-term cosmetic orthodontics,
are recommended to follow recently
published standards for cosmetic
practice.
R. A. C. Chate1
Until recently, cosmetic dentistry has focused on the use of traditional restorative techniques, bleaching and the so-called
facial rejuvenators such as injectable dermal fillers and Botox. More latterly, the short-term use of aesthetic removable
aligners and ceramic fixed appliance brackets have been promoted for use by general dental practitioners as a means of
minimising the invasive amount of restorative dental treatment that would otherwise be required to achieve the desired
degree of aesthetic improvement. Nevertheless, there are inherent risks and complications associated with short-term
orthodontic treatments that are deliberately limited in their outcomes and these, together with the potential ramifications
for the long-term dental health of patients, are discussed.
INTRODUCTION
Over the last few years, as a result
of cosmetic makeover and ‘ten-years
younger’ television programmes, both
public interest and demand for cosmetic
dentistry have risen and as a consequence,
so has the insidious pressure on dental
professionals to comply for fear that
this could otherwise adversely affect
their practices.
A recent publication entitled Short-term
cosmetic orthodontics for general dental
practitioners,1 as well as the subsequent
correspondence that this generated, 2,3
together with a presentation made by Mr
Maini, the Vice President of the British
Academy of Cosmetic Dentistry, on this
topic at the British Dental Association
Annual Conference on 27 April 2013 has
raised some important issues.
The main tenet that is being proposed is
to offer adult patients who do not wish to
have either full orthodontic treatment to
comprehensively straighten their teeth or
extensive porcelain ceramic restorations to
camouflage their anterior misalignment a
Vice Dean, Faculty of Dental Surgery, The Royal
College of Surgeons of Edinburgh, Nicolson Street,
Edinburgh, EH8 9DW
Correspondence to: Robert Chate
Email: [email protected]
1
Refereed Paper
Accepted 15 August 2013
DOI: 10.1038/sj.bdj.2013.1140
© British Dental Journal 2013; 215: 551-553
third choice; namely a course of short-term
orthodontic treatment to gain sufficient
anterior alignment to allow less invasive
restorative dentistry to achieve a pleasing
smile. On first appearances, this would
seem to be a laudable suggestion.
INFORMED CONSENT
As has been debated previously,3 such an
approach is dependent on the patient having
been given sufficient information about all
of the available treatment options for them
to be able to consent to such a procedure.
For the consent to be valid, it is critical
that this must ensure there is a complete
understanding of the probable long-term
consequences that could be faced, should
a ‘quick-fix’ option be followed.
COLLATERAL RAMIFICATIONS
In essence, short-term orthodontic
treatments that reposition anterior teeth
to facilitate their minimally invasive
aesthetic restoration must involve intercanine expansion and incisor proclination,
both of which are inherently unstable
orthodontic movements. To counter this,
post-treatment permanent retention with
either a removable clear ‘essix’ type of
retainer or a lingual bonded retainer is
correctly emphasised.1
However, even though randomised
trials have shown that nocturnal wear
rather than full-time wear of clear overlay
BRITISH DENTAL JOURNAL VOLUME 215 NO. 11 DEC 7 2013
retainers (COR) is sufficient to maintain
orthodontic alignment,4–6 within the first
year of retention another randomised
controlled trial has shown that 27% and
22% of maxillary and mandibular CORs
respectively, are usually lost by patients
and that 31% and 49% respectively, often
end-up broken.7
The situation is no better even if multistrand bonded wire retainers are considered.
Over the short-term, prospective studies
have shown that 37.9% of lingual bonded
mandibular retainers fail within the first
six months of placement,8 as do 58.2%
overall of palatal bonded maxillary
retainers where operator inexperience
correlates with higher failure rates.9
In addition, over the medium-term a
randomised trial has shown that 22.2% of
maxillary and 15.6% of mandibular multistrand wire retainers detach, while 16.7%
and 15.6% end-up breaking, respectively.10
Over the longer term, a similar 25%
failure rate has also been found with rigid
mandibular canine-to-canine bonded
retainers and of those that survived 38%
required repair, of which half were on more
than one occasion.11
The durability and longevity of different
types of retainers is of importance for
patients who have had a limited course
of orthodontic treatment that without
retention is immediately unstable,
because the effect of a retainer that
551
© 2013 Macmillan Publishers Limited. All rights reserved
OPINION
Truth or consequences: the
potential implications of
short-term cosmetic orthodontics
for general dental practitioners
OPINION
eventually fails is rapid relapse of the
original misalignment.
ETHICAL DILEMMA
This therefore poses a dilemma; whether
undertaking a course of short-term
orthodontic treatment that is critically
reliant on the indefinite integrity of a
permanent retention regime is actually
ethical, when fallibility is inherent in
everything man-made or used. The answer
is it is, so long as the patient is apprised
of all the risks, benefits and consequences
that are associated with the proposed
treatment and they have the capacity
to consent.
CLINICAL CONSEQUENCES
The consequences for a patient who
experiences relapse after having had a
course of short-term cosmetic orthodontics
would be threefold. Firstly, they would
need either to have a repeat course of
orthodontic treatment to regain alignment
of their minimally restored teeth, or
secondly, have more destructive restorative
treatment than originally intended in
order to camouflage the misalignment
relapse instead.
If neither of these two rescue remedies
are accepted, either because of the patient’s
dissent or because of their financial
circumstances, the third consequence
would be a very disappointed, disillusioned
and justifiably aggrieved patient.
However, should the patient consent
to either of the two recovery treatments
this would expose them to adverse
biological effects and in relation to
the option of having more extensive
ceramic crown restorations, the risks and
consequences associated with these are
well documented.12,13
In the case of orthodontics, it is commonly
known that a small amount of apical
resorption occurs following a conventional
course of orthodontic treatment. However,
there are a number of factors that can
significantly increase both the risk and
extent of root resorption.14 One of these is
through the use of orthodontic ‘jiggling’
forces,15 where teeth are cyclically exposed
to forward and backward tipping forces,
as would be the case in a patient who
had had initial short-term orthodontic
anterior alignment, relapse and then
subsequent realignment.
The resorptive process involves
osteoclasts, large multinucleate giant
cells16 and the biological response to
tipping forces that jiggle the teeth is to
produce a marked increase in alveolar
bone marrow spaces that are lined by a
multitude of osteoclasts, in particular
within the coronal region.17
That tipping tooth movements
predominate in short-term orthodontics
is acknowledged1 and this type of tooth
movement results in maximum stresses
and strains in the periodontal ligament
(PDL) at the root apex and the alveolar
crest of the teeth; so much so that in some
instances the hydrostatic stresses exceed
the body’s systolic pressure, which can
lead to the induction of PDL necrosis and
a reactionary osteoclastic response.18
When orthodontic forces applied to teeth
are not evenly spread over the root surface
(as in the case of tipping), the forces can be
focal and greater around certain regions.16
As such, orthodontic tooth movement has
been highlighted as a possible factor in the
development of external cervical resorption
(ECR), where excessive forces in the cervical
region (as may occur inadvertently in
inexperienced hands) may induce necrosis
and inflammation adjacent to dentine,
stimulating odontoclastic differentiation
followed by resorption. Surprisingly,
the onset of ECR in these patients has
been demonstrated to occur even after
completion of the orthodontic treatment!16
IMPLICATIONS FOR
PATIENT MANAGEMENT
For a patient considering restorative
cosmetic dentistry to be able to give valid
consent, they should be given evidencebased information, in a form and language
they can understand, on all of the potential
treatment’s limitations,12 such as the mean
finite ten-year longevity of porcelain
veneers as well as the potential one third to
two thirds amount of sound anterior tooth
substance that would need to be removed
if either veneers or full coverage crowns
were to be provided respectively.13
This should also be the case before a
patient embarks upon a course of shortterm orthodontics, on the basis that
should their initial alignment ultimately
be lost they may subsequently choose
to have a restorative option to affect an
aesthetic recovery.
552
For the same reason, they should also
be advised about the root resorption risks
associated with repetitive orthodontic
tipping forces should further courses
of simplistic orthodontic realignment
treatment need to be chosen by them in
the future instead.
Therefore, with the above in mind,
from the outset such patients should be
given evidence-based information on
the longevity, durability and success
of ‘permanent’ retainers so that they
may estimate the potential likelihood
of ever having to face making such
crucial decisions.
DENTAL MATURATIONAL
AGE CHANGES
On the subject of life-long orthodontic
retention, it has been insinuated that
without this even those patients that have
had comprehensive, idealised treatment are
otherwise as equally prone to experience
mal-alignment relapse.19
This is untrue if the definition of the
word ‘relapse’ is strictly applied because,
unlike cases that have had short-term
orthodontics, the teeth of malocclusions
that have been comprehensively corrected
do not immediately relapse upon
withdrawal of the retainers at the end of a
conventional period of retention.
Nevertheless, it is well documented that
up to 70% of patients who have received
previous fixed appliance orthodontic
treatment re-experience dental irregularity
many years, if not several decades later.
This is irrespective of whether they were
treated with dental extractions or not, or
whether their arch widths were deliberately
expanded, constricted or kept unchanged.
However, exactly the same occurs with
untreated normal occlusions, although to
a much lesser extent.20
In all, there is a measurable, life-long
incessant reduction in dental arch widths
and dental arch lengths that lead to late
dental crowding.20,21
Therefore, these changes are now
regarded as normal, albeit undesirable
maturational developments consequential
to ageing.22
As a result, many patients who have
completed a course of conventional
orthodontic treatment and subsequent
retention are advised to continue wearing
their retainers on a part-time indefinite
BRITISH DENTAL JOURNAL VOLUME 215 NO. 11 DEC 7 2013
© 2013 Macmillan Publishers Limited. All rights reserved
OPINION
basis, not because their corrected
malocclusions are inherently unstable,
but to mitigate the unfavourable dental
arch changes that are associated with
getting older. Needless to say, should
their retainers either detach, become lost
or break, there is not the same remedial
urgency as there would be in a retained
case that is inherently unstable.
REGULATION AND
PROFESSIONAL STANDARDS
Cosmetic interventions are a booming
industry in the UK with a projected value
of £3.6 billon by 2015 and in the light
of the Poly Implant Prosthese breast
implant scandal, the Department of
Health commissioned a group to review
the regulation of this sector of clinical
practice.
The chair of the group, Sir Bruce
Keogh, has prefaced the group’s report
with the following statement ‘Those
having cosmetic interventions are often
vulnerable. They take their safety as a
given and assume regulation is already in
place to protect them.’23
The report’s main recommendation is for
the Royal College of Surgeons to establish
an Inter-speciality Committee on cosmetic
surgery in order to set standards for
cosmetic practice and training and to make
arrangements for formal certification.
The report acknowledges that people
considering cosmetic procedures have
a natural tendency to focus on outcome
and in contrast to an apprehensive
patient required to undergo a significant
procedure, they may not pay enough
attention to limitations and underplay the
risks. In these instances, the report urges
cosmetic practitioners to manage people
as patients and not consumers when
undertaking consent and to put the safety
and health of individuals ahead of any
commercial interests.23
In addition, a separate document entitled
Professional standards for cosmetic
practice has been published recently and
this is aimed at all cosmetic healthcare
professionals, including nurses and dentists
who are involved in cosmetic treatments,
irrespective of whether these are either
reversible or irreversible.24 Among other
things, in relation to consent discussions
with patients, the proposed standards
expected of practitioners should be that
they have provided sufficient information
for patients to be able to know:
•What is involved in the proposed
procedure
•What the likely outcome will be
and whether this will meet their
expectations
•The risks and what complications
might occur in both the short- and
long-term and how these will be
managed and paid for
•What other alternative treatment
options may offer
•What the consequences would be
of doing nothing.
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In relation to professional conduct,
the same document advises practitioners
to make clear to patients what their
qualifications are and where appropriate,
whether they are on a specialist list and
what this entails. Creating the impression
of specialist knowledge without specialist
registration should be avoided and since
cosmetic practices are not recognised
specialties, the use of self-descriptive
terms such as ‘cosmetic dentist’ is to
be discouraged.24
In the light of the nationwide reviews
in cosmetic practices, the deans of the
four UK dental faculties have recently
written to Lord Howe, the Parliamentary
Under Secretary of State for Quality,
offering their expertise in progressing any
further reviews on developing standards
and regulations for cosmetic dentistry.
Given time, these will no doubt come to
pass. In the interim, it would behove all
dentists involved in short-term cosmetic
orthodontics to take note and to review
their current practices accordingly.
BRITISH DENTAL JOURNAL VOLUME 215 NO. 11 DEC 7 2013
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Maini A. Short-term cosmetic orthodontics for
general dental practitioners. Br Dent J 2013;
214: 83–84.
Kirschen R. Short-lived benefits. Br Dent J 2013;
214: 325.
Slater R, Hunt N. Providing a choice. Br Dent J 2013;
214: 325–326.
Gill D S, Naini F B, Jones A, Tredwin C J. Part-time
versus full-time retainer wear following fixed
appliance therapy: a randomized prospective
controlled trial. World J Orthod 2007; 8: 300–306.
Thicket E, Power S. A randomized clinical trial of
thermoplastic retainer wear. Eur J Orthod 2010;
32: 1–5.
Jaderberg S, Feldman I, Engstrom C. Removable
thermoplastic appliances as orthodontic retainers a prospective study of different wear regimes. Eur J
Orthod 2012; 34: 475–479.
Sun J, Yu Y C, Chen L et al. Survival time comparison
between Hawley and clear overlay retainers: a
randomized trial. J Dent Res 2011; 90: 1197–1201.
Taner T, Aksu M. A prospective clinical evaluation of
mandibular lingual retainer survival. Eur J Orthod
2012; 34: 470–474.
Schneider E, Ruf S. Upper bonded retainers. Angle
Orthod 2011; 81: 1050–1056.
Bolla E, Cozzani M, Doldo T, Fontana M. Failure
evaluation after a 6‑year retention period: a
comparison between glass fibre-reinforced (GFR)
and multistranded bonded retainers. Int Orthod
2012; 10: 16–28.
Booth F A, Edelman J M, Proffit W R. Twenty-year
follow-up of patients with permanently bonded
mandibular canine-to-canine retainers. Am J Orthod
Dentofacial Orthop 2008; 133: 70–76.
Merivale J. Cosmetic dentistry: a risky business?
Faculty Dental Journal 2011; 2: 73–78.
Kelleher M. Ethical issues, dilemmas and
controversies in ‘cosmetic’ or aesthetic dentistry.
A personal opinion. Br Dent J 2012; 212: 365–367.
Weltman B, Vig K W L, Fields H W, Shanker S, Kaizar
E E. Root resorption associated with orthodontic
tooth movement: A systematic review. Am J Orthod
Dentofac Orthop 2010; 137: 462–476.
Brezniak N, Wasserstein A. Root resorption after
orthodontic treatment: Part 2. Literature review. Am
J Orthod Dentofac Orthop 1993; 103: 138–146.
Darcey J, Qualtrough A. Resorption: part 1.
Pathology, classification and aetiology. Br Dent J
2013; 214: 439–451.
Polson A M, Meitner S W, Zander H A. Trauma and
progression of marginal periodontitis in squirrel
monkeys III. Adaption of interproximal alveolar
bone to repetitive injury. J Periodontal Res 1976;
11: 279–289.
Field C, Ichim I, Swain M et al. Mechanical responses
to orthodontic loading: A 3‑dimensional finite
element multi-tooth model. Am J Orthod Dentofac
Orthop 2009; 135: 174–181.
Maini A. Response to ‘Providing a choice’. Br Dent J
2013; 214: 326.
Little R M. Stability and relapse of dental arch
alignment. Br J Orthod 1990; 17: 235–241.
Tsiopas N, Nilner M, Bondemark L, Bjerklin K. A
40 years follow-up of dental arch dimensions and
incisor irregularity in adults. Eur J Orthod 2013;
35: 230–235.
Sinclair P M, Little R M. Maturation of untreated
normal occlusions. Am J Orthod 1983; 83: 114–123.
Keogh B. Review of the regulation of cosmetic
interventions. London: Department of Health, 2013.
Cannon S. Professional standards for cosmetic
practice. London: The Royal College of Surgeons of
England, 2013.
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© 2013 Macmillan Publishers Limited. All rights reserved